Inguinal Hernias: Diagnosis and

Management
KIM EDWARD LeBLANC, MD, PhD; LEANNE L. LeBLANC, MD; and KARL A. LeBLANC, MD, MBA
Louisiana State University School of Medicine, New Orleans, Louisiana

Inguinal hernias are one of the most common reasons a primary care patient may need referral for surgical interven-
tion. The history and physical examination are usually sufficient to make the diagnosis. Symptomatic patients often
have groin pain, which can sometimes be severe. Inguinal hernias may cause a burning, gurgling, or aching sensation
in the groin, and a heavy or dragging sensation may worsen toward the end of the day and after prolonged activity.
An abdominal bulge may disappear when the patient is in the prone position. Examination involves feeling for a bulge
or impulse while the patient coughs or strains. Although imaging is rarely warranted, ultrasonography or magnetic
resonance imaging can help diagnose a hernia in an athlete without a palpable impulse or bulge on physical exami-
nation. Ultrasonography may also be indicated with a recurrent hernia or suspected hydrocele, when the diagnosis
is uncertain, or if there are surgical complications. Although most hernias are repaired, surgical intervention is not
always necessary, such as with a small, minimally symptomatic hernia. If repair is necessary, the patient should be
counseled about whether an open or laparoscopic technique is best. Surgical complications and hernia recurrences
are uncommon. However, a patient with a recurrent hernia should be referred to the original surgeon, if possible.
(Am Fam Physician. 2013;87(12):844-848. Copyright 2013 American Academy of Family Physicians.)

H
Patient information: ernia is a general term describ- hernia occurrence. Several studies have

A handout on this topic,
written by the authors
of this article, is avail-
able at http://www.
aafp.org/afp/2013/0615/
p844-s1.html. Access to
the handout is free and
unrestricted.
CME This clinical content
conforms to AAFP criteria
for continuing medical
education (CME). See CME
Quiz on page 833.
Author disclosure: No rel-
evant financial affiliations.
ing a bulge or protrusion of
an organ or tissue through
an abnormal opening within
the anatomic structure. Although there
are many different types of hernias, they
are usually related to the abdomen, with
approximately 75% of all hernias occurring
in the inguinal region.1 Abdominal wall her-
nias account for 4.7 million ambulatory care
visits annually. More than 600,000 surgical
repairs for inguinal hernias are performed
nationwide each year,2 making it one of the
most common general surgical procedures
performed in the United States.
Inguinal hernias have a 9:1 male pre-
dominance,3 with a higher incidence among
men 40 to 59 years of age. It has been esti-
mated that more than one-fourth of adult
men in the United States have a medically
recognizable inguinal hernia.4 Men with a
diagnosed hiatal hernia have been shown
to have double the risk of an inguinal her-
nia. Among women, taller height, chronic
cough, umbilical hernia, older age, and rural
residence have been associated with a higher
incidence of inguinal hernia. Neither smok-
ing nor alcohol use has been shown to affect
demonstrated that men who are overweight
or obese have a lower risk of inguinal hernia
than men of normal weight.4,5
Although this article focuses on inguinal
hernias, other diagnostic possibilities should
be considered in a patient with groin pain
(Table 1). In athletes, groin pain most com-
monly results from an overuse injury asso-
ciated with adductor tendons and muscles,
and a specific differential diagnosis should
be considered in these patients (Table 2).6,7
Any mass palpated in the inguinal region
should prompt a thorough clinical evalua-
tion because there are many possible diag-
noses (Table 3).
Symptoms and Physical Findings
The diagnosis of an inguinal hernia is usu-
ally made through history and physical
examination findings. Although data are
limited, in one report, the sensitivity and
specificity of the physical examination were
75% and 96%, respectively.8
Symptoms of an inguinal hernia may
appear gradually over time or develop sud-
denly, as with incarceration (i.e., the contents
of the hernia sac cannot be returned to the

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 Inguinal Hernias

abdominal cavity). Inguinal hernias may be asymptom- experience a heavy or dragging sensation in the groin,
atic and found incidentally on routine physical exami- especially toward the end of the day and after prolonged
nation. Symptomatic patients often present with groin activity.1 Activities that increase intra-abdominal pres-
pain, which can be severe. Stretching or tearing of the sure, such as coughing, lifting, or straining, cause more
tissue at and around the hernia defect can lead to a burn- abdominal contents to be pushed through the hernia
ing, gurgling, or aching sensation in the groin. This usu- defect. As this occurs, the bulge of the hernia gradually
ally causes localized pain directly at the site of the hernia. increases in size. If the patient indicates that this bulge
Pain may worsen with Valsalva maneuvers. Patients may disappears while he or she is in the supine position, clini-
cal suspicion of a hernia should be increased.
Hernias may be easily diagnosed with an adequate
Table 1. Differential Diagnosis physical examination. The physical examination should
of Groin Pain begin by carefully inspecting the femoral and inguinal
areas for bulges while the patient is standing. Then, the
Adhesions Lumbar disk disease patient should be asked to strain down (i.e., Valsalva
Appendicitis Meralgia paresthetica maneuver) while the physician observes for bulges. This
Athletic pubalgia (sports hernia) Pelvic pathology (osteitis may be accomplished by using the right hand to exam-
Diverticulosis/diverticulitis pubis, adductor strain)
ine the patients right side and the left hand to exam-
Hip pathology (osteoarthritis, Prostatitis
ine the patients left side. The physician invaginates the
avascular necrosis of Testicular disorders
femoral head)
loose skin of the scro-
Urinary tract infection
Inflammatory bowel disease
tum with the index
Chronic pain is the most
finger on the ipsilat-
common long-term
eral side of the patient,
issue after hernia repair.
starting at a point low
Table 2. Differential Diagnosis of Groin Pain enough on the scro-
in Athletes tum to reach as far as the internal inguinal ring. Starting
on the scrotum, the examining finger follows the sper-
Diagnosis Clinical presentation matic cord upward above the inguinal ligament to the
triangular, slit-like opening of the external inguinal ring.
Avulsion fractures History of sudden or forceful muscle
contraction, tenderness over bony
The external inguinal ring is medial to and just below
prominence, ecchymoses the pubic tubercle. The inguinal canal is gently followed
Ligamentous sprains History of trauma or fall, sudden laterally in its oblique course. While the examining fin-
onset ger is in the canal next to the internal inguinal ring, the
Muscle strains History of sudden onset during patient strains down or coughs as the physician feels for
muscle contraction any palpable herniation.9 The diagnosis of an inguinal
Nerve entrapment Associated paresthesias or hernia is confirmed if an impulse or bulge is felt.
syndromes numbness If no bulge is detected with a Valsalva maneuver, a
Osteitis pubis Tenderness over symphysis pubis hernia is unlikely. However, athletic pubalgia (sports
Referred pain from Associated findings in these areas hernia) may be considered in athletes with groin pain
lumbar, hip, or
sacroiliac area
and no bulge. A sports hernia is not a true hernia, but
Sports hernia History of high-intensity athletic
rather a tearing of tissue fibers. This typically occurs in
activity, typical symptoms of patients with a history of high-intensity athletic activity.
hernia with no evidence on Although these patients have typical hernia symptoms,
physical examination, pain there is no evidence on physical examination. Further
with forced adduction against follow-up and reexamination are needed to diagnose a
examiners resistance
sports hernia. Pain along the symphysis pubis suggests
Stress fractures History of repetitive motion activity
or overuse, tenderness over bone
osteitis pubis, whereas pain along the adductor tendons
Tendinopathies Pain with motion and contraction of
suggests adductor tendinopathy.
specific muscle It is more challenging to diagnose a hernia in female
patients. Direct palpation with an open hand over
Information from references 6 and 7. the groin area might detect the impulse of a hernia
during a Valsalva maneuver. However, further workup

June 15, 2013 Volume 87, Number 12 www.aafp.org/afp American Family Physician845
Inguinal Hernias

with diagnostic testing or referral to a sur-

geon is often indicated. Rarely, diagnostic Table 3. Differential Diagnosis of Groin and Scrotal
laparoscopy is necessary. Masses
Incarceration may be managed in the
office setting if there is no associated pain. Diagnosis Clinical presentation
The standard of care is to place the patient
Ectopic testis Absence of a testis in the scrotum
in the Trendelenburg position while holding
Epididymitis Severe pain surrounding the testis, tenderness,
gentle pressure on the area for up to 15 min- fever, chills
utes. If acute onset of groin pain occurs, the Femoral adenitis/ Bilateral, firm, tender nodes; fever
hernia may have become strangulated (i.e., adenopathy
the blood supply to the entrapped contents Femoral arterial Older patient, pulsatile mass, no systemic symptoms
is compromised). Strangulation should be aneurysm
suspected in the presence of tenderness, red- Femoral hernia More common in women, often incarcerated, bowel
ness, nausea, and vomiting and is a surgical obstruction
emergency.10 Hematoma Associated trauma, ecchymoses, tenderness, no
change with Valsalva maneuver
Imaging Hidradenitis Draining abscesses in intertriginous skin of the groin
Hydrocele Mass in the scrotum or inguinal canal that
Although imaging is rarely needed to diag-
transilluminates
nose a hernia, it may be useful in certain
Inguinal adenitis/ Tenderness, redness possible, often bilateral,
clinical situations (e.g., suspected sports her- adenopathy systemic symptoms
nia; recurrent hernia or possible hydrocele; Inguinal hernia Bulge or impulse detected in inguinal canal with
uncertain diagnosis; surgical complications, Valsalva maneuver or coughing
especially chronic pain).8 The clinical use of Lipoma Soft, asymptomatic mass; does not change in size
ultrasonography has shown promise in these Lymphoma Firm, tender mass; may increase in size;
situations.11,12 The sensitivity of ultrasonog- organomegaly; systemic symptoms
raphy for the detection of groin hernias is Metastatic Firm, tender mass; may be enlarging; systemic
greater than 90%, and the specificity is 82% neoplasia symptoms or weight loss
to 86%. 8,13 Psoas abscess Flank or back pain, fever, inguinal mass, limp,
weight loss
Use of higher resolution axial computed
Sebaceous cyst Soft mass, nontender, more superficial, no change
tomography in the diagnosis of inguinal
with Valsalva maneuver
hernia is being investigated. Magnetic res-
14
Testicular torsion Acute onset of pain with a high-riding testis,
onance imaging may be useful in differen- swelling, very tender
tiating inguinal and femoral hernias with a Varicocele Usually asymptomatic or dull ache, unilateral bag
high sensitivity and specificity (greater than of worms in scrotum
95%).8 The use of magnetic resonance
imaging is helpful in the diagnosis of ath-
letic pubalgia or sports hernias, which may occur at and strangulation, and to seek prompt evaluation if these
any age with potentially more than one cause. The occur.16,17 Patients with symptomatic, large, or recurrent
physician may consider magnetic resonance imaging hernias should be referred for repair, generally within
in the workup of patients with activity-related groin one month of detection.18 Hernia repair almost always
pain when no inguinal hernia can be identified on involves some type of prosthetic material (i.e., mesh),
physical examination.15 with the possible exception of women of childbearing age
because stretching of tissues during pregnancy may result
Surgical Management in a recurrent hernia. The choice of mesh material used in
In the past, surgical repair was recommended for all the repair is based on the surgeons preference.
inguinal hernias because of the risk of complications such The choice of open vs. laparoscopic repair depends on
as incarceration or strangulation. However, recent stud- surgeon preference, but only about 10 percent of ingui-
ies have proved that small, minimally symptomatic, first nal hernia repairs in the United States are performed
occurrence hernias do not necessarily require repair, and via a laparoscopic technique.19 Open repair may be
these patients can be followed expectantly. However, they particularly beneficial in older, less healthy patients.20
should be counseled on the symptoms of incarceration Laparoscopic repair is usually reserved for recurrent

846 American Family Physician www.aafp.org/afp Volume 87, Number 12 June 15, 2013
 Inguinal Hernias

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References

Although imaging techniques such as ultrasonography, computed tomography, and magnetic C 18

resonance imaging are rarely needed to diagnose inguinal hernias, they may be useful in certain
clinical situations.
Ultrasonography has good sensitivity and specificity for the detection of groin hernias. C 8
Small, minimally symptomatic, first hernias do not necessarily require repair, and these patients C 16, 17
may be followed expectantly. They should be counseled on symptoms of incarceration or
strangulation, and to seek prompt evaluation if these occur.
Patients with symptomatic, large, or recurrent inguinal hernias should be referred for repair, C 18
generally within one month of detection.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.
org/afpsort/.

or bilateral hernias. Open and laparoscopic techniques
have similar results (Table 4).21-24 Both procedures are
effective if performed by an experienced surgeon, and
have a recurrence rate from 0% to 9.4%.25,26
The most common complications of hernia repair
are hematomas, including penile or scrotal ecchymo-
sis; seromas; and wound infection. Although these
are uncommon, family physicians should be vigilant
Table 4. Comparison of Laparoscopic and Open
Techniques to Repair Primary Inguinal Hernias
Outcome Comparison
because patients may present to them postoperatively.
Chronic pain is the most common long-term problem
after hernia repair, occurring in 5% to 12% of patients,
and is related to nerve scarification, mesh contraction,
chronic inflammation, or osteitis pubis.27,28 Treating her-
nia repair complications can be challenging, and these
patients are often referred to the operating surgeon.29
Postoperative Care
The current standard of care after hernia repair is gen-
eral wound care. The length of required inactivity varies
greatly based on the surgeons preference, but activity is
usually permitted within two to four weeks for laborers
and within 10 days as tolerated for professionals.30,31

Operative time Longer with laparoscopy21-23 Data Sources: The literature search was conducted using the keywords
hernia, hernia surgery, groin pain, and laparoscopic repair. We searched
Equal24 the Centers for Disease Control and Prevention, Cochrane Database of
Length of hospital stay Shorter with laparoscopy22,23 Systematic Reviews, Agency for Healthcare Research and Quality Evi-
Equal21,24 dence Reports, National Guidelines Clearinghouse, Institute for Clinical
Complications More common with open Systems Improvement, U.S. Preventive Services Task Force, and Essential
Evidence Plus. Search date: May 2, 2011, through May 6, 2011.
technique23
Equal21,22,24 The authors thank Christine L. Manalla for her assistance in the writing
Return to usual activity Earlier with laparoscopy21-23 and preparation of the manuscript.
Chronic pain More common with laparoscopy21
Equal24 The Authors
Chronic numbness More common with laparoscopy21
KIM EDWARD LeBLANC, MD, PhD, FAAFP, FACSM, is the Bernard and
Equal24 Marie Lahasky professor and head of the Department of Family Medicine
Hernia recurrence Equal21-24 at Louisiana State University School of Medicine in New Orleans. He is
also a professor in the universitys Department of Orthopedics and has a
NOTE: It appears that laparoscopic repair increases operative time, but certificate of added qualification in sports medicine.
is associated with better patient outcomes and equal recurrence rates
compared with open repair. LEANNE L. LeBLANC, MD, FAAFP, is a family physician in private practice
at JenCare Neighborhood Medical Centers in Kenner, La. At the time the
Information from references 21 through 24. article was written, she was an assistant professor of family medicine at
Louisiana State University School of Medicine.

June 15, 2013 Volume 87, Number 12 www.aafp.org/afp American Family Physician847
Inguinal Hernias
KARL A. LeBLANC, MD, MBA, FACS, is a clinical professor of surgery at
Louisiana State University School of Medicine. He is also associate medical
director of Our Lady of the Lake Physician Group and director and program
chair of the fellowship program at the Minimally Invasive Surgery Institute
in Baton Rouge, La.
Address correspondence to Kim Edward LeBlanc, MD, PhD, FAAFP,
FACSM, Louisiana State University School of Medicine, 1542 Tulane
Ave., Box T1-8, New Orleans, LA 70112 (e-mail: klebla@lsuhsc.edu).
Reprints are not available from the authors.
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